Payment Reform

CMS’s Andrew Slavitt talks with MMS about MACRA

Posted in Electronic Medical Records, Health Policy, Health Reform, Payment Reform, Regulation on May 26th, 2016 by MMS Communications – Comments Off on CMS’s Andrew Slavitt talks with MMS about MACRA

Editor’s Note: On April 27, 2016, the Department of Health and Human Services issued a Notice of Proposed Rulemaking to implement key provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), bipartisan legislation that replaced the flawed Sustainable Growth Rate formula with a new approach to paying clinicians for the value and quality of care they provide.  In early May, the Massachusetts Medical Society sat down with Andrew Slavitt, Acting Administrator of the Centers for Medicare and Medicaid Services, to talk about the new rule and how it was developed.  More information on the Proposed Rule can be found here.

MMS:  Recently you said that you thought CMS had lost the hearts and minds of America’s doctors, and the new MACRA rule was an opportunity to win them back. Can you tell us how you got to that point and why you think the new proposed rule will change physicians’ perceptions?

CMS Acting Administrator Andrew Slavitt

CMS Acting Administrator Andrew Slavitt

MR. SLAVITT: I want to start with mentioning that the Quality Payment Program that we put out in a proposal comes at a very exciting time in the evolution of Medicare. The implementation of MACRA allows us to take the next transformative step in the Medicare program, by introducing the Quality Payment Program to pay physicians and other clinicians for quality, with a more flexible approach, common-sense approach.  MACRA repealed the SGR and streamlined the patchwork of Medicare programs that currently measure value and quality into a single framework where every physician and clinician has the opportunity to be paid more for providing better care for their patients.  MACRA builds on the important reforms of the Affordable Care Act, which increased the numbers of Medicare clinicians participating in alternative payment models, which are models that reward coordinated, innovative care.

But, there is a lot of fatigue that has come with all the changes over the years. We know it can feel like there are people that sit around thinking of ideas for how to make a physician’s job more difficult; when what is really happening is the accumulation of requirements over time, passed in a series of laws or that come through a series of regulations. If people don’t implement and manage them carefully, we end up in a situation where I think we are now –  where despite all of the best intentions, the burdens add up for those on the front lines where care is given or received.

If people don’t feel like they’re being heard, if they don’t feel like they have a voice, and if they don’t feel like the changes make sense for their practice, it can be incredibly demotivating.

We have approached the implementation of MACRA with the belief that physicians know best how to provide high quality care to our beneficiaries.  And we have taken an unprecedented effort to draft a proposal that is based directly on input from those on the front line of care delivery.  Before drafting the Quality Payment Program proposal, we reached out and listened to over 6,000 stakeholders, including state medical societies, physician groups, and patient groups to understand how the changes we are proposing may positively impact care and how to avoid unintended consequences.

The feedback we received shaped our proposed rule in important ways—and the dialogue is continuing. Based on what we learned, our approach to implementation is being guided by four principles, which I think are also consistent with the goals of the MACRA legislation.

  • One is to keep the patient at the center, always.
  • Two, give physicians more flexibility to control their own destiny and to control what gets measured, how it gets measured and have a little bit more say in how things work, because I think that flexibility is a critical ingredient to some of the issues that we talked about.
  • Three, is simply to do less. Find opportunities wherever we can to reduce the burden. It’s as simple as that.
  • Fourth is simplify, simplify, simplify. That is something we try to take an opportunity to do in every place we could, whether it’s in the use of technology, whether it’s in taking this patchwork of programs and consolidating them and, it will be in how we ultimately implement many of the other components. We have an opportunity to really make a big change. What we’re going to have to do well is continue to listen, provide as much flexibility as possible and simplify.

At the end of the day, after thoughtful and skillful execution, it will be time that tells us how well we have done.

MMS:  You also talk about user-driven policy design. Can you talk about what that means and how it influenced the new Meaningful Use rules now called Advancing Care Information?

MR. SLAVITT: Sure. It’s actually not that radical a concept in the real world. In the real world it might be called “talking to your customers about what they want.” Perhaps in Washington, though, it is a bit of a new concept.

A great example of user-driven policy design would be the visit that you led us on when we were in Massachusetts: Sitting down and listening to what people who deliver care say about the impact of our work at CMS. There is no magic to it: just listen; translate needs into actions; create and deliver; communicate and seek further input; continue to iterate.

In a nutshell the big trap when doing public policy is to do it from your desk. The opportunity we all have – and it’s quite exciting for the people in the agencies – is to really get out there and think about what it feels like at the kitchen table of the American family, what it feels like in the clinics where people get care and how to improve on that. It is a wholesale different way of approaching this work.

When we implemented ICD-10, we used a bit of this approach, I think successfully. We are attempting to roll it out more significantly with the Quality Payment Program. I think you’re exactly right, the Advancing Care Information proponent of MIPS is a critical aspect which we took in a significant amount of input on.

And like I said, continuing to listen and iterate is a very important aspect of user-driven policy design. We are in the phase now of listening to input. And even after we publish the final rule, we will listen and iterate.

MMS:  You’ve also compared the new MACRA proposal to the rollout of an iPhone. So if you’ll forgive me for expanding on that analogy, even in Massachusetts there are physicians who are still using flip phones. You’ve also said, and I’m paraphrasing, that it’s okay to have payment models that aren’t perfect as long as we learn from them. How do you see these perspectives fitting into the implementation of MACRA, e.g., opportunities for physicians who are not used to taking on risk, learning how to bear more risk without fearing that they’re going to lose their practices?

MR. SLAVITT: It’s really important to put in context what payment model and incentives are supposed to do. I have never met a physician, nor do I hope to meet a physician, who makes decisions on patient care based upon how they’re going to get paid. I don’t think that’s how physicians are wired.

The role of payment models and incentives is simply to reinforce what the clinician believes to be the right way to deliver care. If incentives are done well and done right, clinicians will get reinforcement financially; and the payment system gives them the opportunity and the dollars to invest and reinvest in the kinds of things that they believe are right for their practice and for their patients. We have to make sure it is clear that we know it is the clinical and cultural leadership that improves quality, not public policy.

The point I was making about the iPhone is that we are in early generations of some of these payment models. The clinicians who participate should be aware that models are meant to reinforce the good practice of medicine, but the models are not going to be perfect. The models are going to have to get better over time based upon how they get used in the real world and improved upon. For instance, in our second generation models we have made changes, like adding telemedicine or adding patient incentives to make sure that the patient is aligned with their physician in staying healthy.

And where did the changes come from?  They came from listening to physicians and patients. The physicians tell us this model would be better if it could do this, if it could do that. And that’s the thinking that has to continue. So, like any other good, user-driven program, we want an ongoing dialogue so that year over year the program improves for patients and clinicians.

MMS:  So on to interoperability, which I know is one of your concerns. You know it’s one of the physicians’ greatest frustrations. Secretary Burwell has said 90 percent of EMR vendors are committed to interoperability, which is great. I think I can hear physicians nationally groaning because they think they’ve heard this before. So what is it that CMS can do and HHS can do to make it real?

MR. SLAVITT: Let’s talk about what interoperability really is. This is such an important ingredient to improving health care. But interoperability in some respects needs to just be as simple as this: how can we collaborate for the best outcomes when a patient is going to experience different parts of our fragmented health care system? What we want out of interoperability is simple: having a patient referred for other care and understanding what happens at that visit; or communicating with the physician when a patient is discharged from the hospital to make sure they are taken care of and are healing at home.

As you mentioned, Secretary Burwell announced that companies representing 90 percent of EHRs are committing to three vital steps to real interoperability. I thank the many who have made this commitment. It has the potential to set us on a new course, but we all need to be more committed than ever to making sure that the substance of this pledge translates to reality.

And you’re exactly right about physicians groaning; we are not talking sending a man to the moon. We are actually expecting technology to do the things that it already does for us every day. So there must be other reasons why technology and information aren’t flowing in ways that match patient care.

Partly, I believe some of the reasons are actually due to bad business practices. But, I think some of the technology will improve through the better use of standards and compliance. And I think we’ll make significant progress through the implementation of API’s in the next version of EHR’s which will spur innovation by allowing for plug and play capability. But the reason that the pledge is important is because the private sector has to essentially change or evolve their business practices so that they don’t subvert this intent.

In some respects, you can look at me and you can look at the government and say, “Why don’t you just mandate that people do this?”  We have very few higher priorities, but the reality is that if we really want change, we need everybody to put pressure on people in the system to make the technology work. So, if you are a customer of a piece of technology that doesn’t do what you want, it’s time to raise your voice. We’re doing everything we can to make sure that the technology vendors stop focusing on meeting the regulations, so they can start focusing on their customers and their users, and design around the physicians’ needs, the caretakers’ needs, the patients’ needs.

MMS:  We reached out to other medical societies nationally to get some questions for this interview, and they’re all interested in MACRA’s Quality Payment Program, including MIPS and APMs. Many of the questions had a pretty common theme: Physicians are willing to be held accountable for what they’re doing and they know they’re going to be graded on it, so to speak, but they’re concerned about being held accountable for things that are not under their control, whether it’s care that’s not under their control or let’s say a non-compliant patient for whatever reason. The other part of it was registries; how can the medical community be more involved and engaged with CMS in the development of these registries. So your thoughts on those two issues?

MR. SLAVITT: They’re very good questions. First, I’ll just go back to my earlier comment, which is that these payment models are intended to be strong signals about the kind of activities that improve patient care. And so, yes, a physician will feel like there are some things that they’ve got to really influence and pieces of the puzzle that they don’t control; we are interested in hearing about those and making sure that those make sense.

However, patient compliance is a tough but critical part of the process, and efforts to communicate to patients and so forth are obviously part of what physicians do and have been doing for a number of years. At the same time, we’re hearing amazing stories from physicians in small practices and rural, underserved communities.  Motivated and driven with a passion for patient care, they are redesigning their care teams around their patient needs in ways that are having dramatic impacts in patient compliance and health outcomes.  Meaningful impacts, such as significantly improving A1C levels – even as practices expanded to take on sicker, under-insured patients – and significant increases on follow through for referrals on behavioral health and addition referrals.  These are improvements that matter in our communities and in our homes.  And we’re hearing physicians say, “This is incredible! We’re practicing medicine again!”

We work very hard to create what we call a core set of measures, which means that we want to be on the same page with every other payer that’s in a physician’s office so that a physician can focus on one way of doing things.

For specialists, we’ve done a lot of work and a lot of collaboration.  Eighty percent of our measure sets are specialty specific, and the vast majority of those measures come from physician leadership outside of CMS where people are saying this is the evidence-based state of practice, this is what we want. We spent a lot of time engaging the clinical community – medical societies and front-line physicians – to design a program that’s equally meaningful to a wide range of specialties that practice in very different settings.  There’s plenty of ways to be successful within the Quality Payment Program. In addition, for small practices, we’ve designed our proposed rule to provide support and flexibility that match their circumstances, including increased technical assistance, exemptions for small volume practices, allowances for medical home models, and a continued focus on reducing reporting burden.  Our teams are set up to evolve these rules and the clinical community needs to continue to be a strong partner in this process.

MMS:  You are in charge of the most powerful agency in the nation to effect changes in health care in this country at the time of greatest change in health care. So what do you see as your role in this position and the role of CMS in helping shape the future of health care?

MR. SLAVITT: I think it’s really to listen to and absorb the voice of the people that are doing great care every day. We have 140 million consumers that are a part of Medicare, Medicaid and the Children’s Health Insurance Program, and the Marketplace.

If you start with that, let’s talk about what their life is like. They’re increasingly mobile. They’re connecting to an often fragmented system where they’re not anchored. Many of these 140 million, the vast majority are on modest incomes or fixed incomes. They may have family-care needs, both with parents and with children. They worry about how they’re going to pay for the next prescription drug or about missing their bus to their next dialysis appointment. They worry about whether health care is going to become too expensive to manage.

So if you keep it at that fundamental level, it makes, I think, our job pretty clear: represent the needs of the people we serve and to make sure those needs are getting met. CMS will continue to shape health care by making sure these programs are preserved, as well as evolve to meet the needs of the patients.

The wrong way to do that is to put a bunch of policy ideas together in a black box and try to implement them.

The best way – and it is very exciting – is to manage these programs by capturing both the voice of the patients and of the voice of the clinicians, represent those the best we can, and drive towards the delivery of high quality care.

MMS:  Is there anything else you want to say?

MR. SLAVITT: I want to thank you all at the Mass. Medical Society for the visit we had in Boston in the physician’s office. It is so important that we figure out how to connect public policy to what happens on the ground and in the real world. It’s invaluable. And we have to keep it up. It’s not one-off. It must be a cultural commitment. In fact, in the month of May alone, we have 35 scheduled events to hear from a wide range of stakeholders and this outreach will remain an important ongoing part of our work. I personally have been meeting regularly with physician groups, including smaller and rural practices, and have spoken to thousands of physicians in different parts of the country about their work, the opportunities and challenges they face, and what this proposal means for them and their patients.

The second thing I’d say is for physicians who are looking at these new regulations, to please get engaged. There is no possible way, for all the thinking our team can do, that we can anticipate every consequence of what we are working on. And as we aim to provide you with meaningful flexibilities, reduce your burden, and simplify how things get done, please help us think about how these programs can fairly and objectively reward you for the quality of care you delivery.

With all of the work that went into the proposal, it is critical that we receive direct feedback from physicians and other stakeholders. We rely heavily on the feedback for people to say, “I see your intent but what is happening is there’s an unintended consequence or there is a better way to lead us.” If physicians don’t get engaged, then consequentially they will feel the impact of things that they really could have influenced, and we want them to see that we are listening.

I know Washington can feel so distant, policy-making can feel so distant, and I think people are just, sheer exhausted for good reason, so sending in feedback can feel too difficult or pointless. But if this is truly able to be moved forward with all the input of the people who take care of all the beneficiaries (who I like to think actually run Medicare every day), then these new improvements will go so much better, and the Medicare program, the patients in these programs, and the practice of medicine will be the better for it.

I recognize that it’s not the talk, but how we act together, that moves things forward. Which is why I think the change from Meaningful Use to this new, much simpler, much more flexible program of Advancing Care Information is so important because it’s intended to be, among other things, a proof point that we’re not just talk. We are willing to look at things that aren’t working and fix them because it’s for the good of our patients, your patients and for the good of the practice of medicine.

 

Ethics Forum: Pay for Performance

Posted in Ethics Forum, Health Reform, Interim Meeting 2014, Payment Reform, Tiering on December 5th, 2014 by MMS Communications – 1 Comment

Since its introduction some ten years ago, Pay-for-Performance (P4P) has been the object of much confusion, conversation and scrutiny in the medical industry.

Such programs have raised a host of practical questions: What criteria do you use to objectively judge performance? How do you develop incentives for accomplishment and penalties for falling short? What principles do you use to guide such programs?

Practical considerations aside, the payment system has also raised some important ethical questions, and those were the focus of the Ethics Forum at the 2014 MMS Interim Meeting on Friday, December 5 presented by the Committee on Ethics, Grievances and Professional Standards.

Offering their perspectives on the topic of Ethics of Pay for Performance were Alyna T. Chien, M.D., M.S., a pediatrician at Boston Children’s Hospital and the lead investigator in four different projects focusing on the effectiveness of payment and quality incentives, and Sachin H. Jain, M.D., M.B.A., Chief Medical Information and Innovation Officer at Merck and Lecturer in Health Care Policy at Harvard Medical School.

“We are in a revolution,” said Dr. Chien, “as the entire organization of medicine is changing, progressing to one of integrated health care.” She noted that most incentives move from the payer to the hospital or physician practice, and that most of the data regarding the impact of P4P programs exists at the organizational level. There’s little data on how it works at the individual physician level.

Dr. Chien believes these performance programs can have one of three effects in delivering care: a neutral effect, where the status quo is preserved; a narrowing of care, where more attention is paid to quality and more programs are tailored to patients; or a widening of care, where gaps will occur between rich and poor and physicians will selectively pick their patients.

Dr. Jain acknowledged that the public perception of the profession has changed and that physicians should be at “a point of soul searching and questioning where we are in society.” He offered a scenario of physicians as either “knights” (motivated by altruism and being the ultimate champion of the patient), “knaves” (driven by self-interest and financial gain), or “pawns” (pushed by rewards and penalties of the system in which they operate).”

While he pointed out that such a framework can also be applied to others (for example, patients, health plans, pharmaceutical companies, nurses, and hospital executives), Dr. Jain believes organized medicine has focused too much on reimbursement and that physicians are perceived not to be trusted to do what’s right unless there’s a carrot or stick approach.

“We are losing our more intrinsic value in favor of pay-for-performance,” Dr. Jain says, “and the intrinsic motivation of doing what’s right for the patient must be preserved. It is what differentiates us from other professions. It is what tells others that we will do the right thing whether we get paid or not.”

His prescription is direct: a proper system of reimbursement must offer a reasonable salary, reject incentive contracting, focus on clinically meaningful measures, make it easy for physicians to do the right thing for patients, and find ways to honor and reward the intrinsic motivation of what’s best for the patient that most physicians have.

Presentations at the Ethics Forum may be viewed here.

Mass. Health Care Costs: Evidence, Testimony, and Scrutiny

Posted in Global Payments, Health Policy, Health Reform, Payment Reform, Payment Reform Commission on October 6th, 2014 by MMS Communications – 1 Comment

“We’re not interested in just saving money, we’re also concerned aboutMassachusetts State House quality and access, but we need to do it in a way that we have the capacity to afford it,” said Stuart Altman, chairman of the Massachusetts Health Policy Commission, as he opened two days of hearings on health care cost trends in Massachusetts at Suffolk University Law School this morning.

Billed as an “opportunity to present evidence and testimony to hold the entire health care system accountable,” the Annual Health Care Cost Trends Hearing represents the first review of the state’s performance under the health care costs growth benchmark established in Chapter 224 in 2012. Over two days, the Commission is examining cost trends for public and commercial payers as well as hospitals and other providers.

Along with health care policy experts making detailed presentations, nearly 30 individuals – a list that reads like a “Who’s Who” of Massachusetts health care – are providing testimony on such topics as meeting the health care cost benchmark, transforming the payment system, coordinating behavioral health and post-acute care, and insurance market trends and provider market trends in promoting value-based health care.

The mood among the HPC commissioners and morning’s presenters as the session began was generally upbeat, as the Center for Health Information and Analysis (CHIA) last month released the first report on the Commonwealth’s performance. With the health care cost growth benchmark set at 3.6 percent, CHIA found that total health care expenditures increased by 2.3 percent , 1.3 percent below the benchmark. Total expenditures reach $50 billion statewide.

Governor Deval Patrick, one of the first to speak and declaring that “health is a public good,” said that “by any measure, Massachusetts health care reform is a success,” at the same time cautioning that even after eight years of health reform “there’s plenty of room to innovate” and “constant refinement” will be needed. Patrick added that challenges remain, chief among them the delivery of primary care.

Jeffery Sanchez, Chair of the legislature’s Joint Committee on Public Health, the second public official to speak, was also upbeat but cautious as well. “Let us continue to show the nation we continue to be a leader,” he said, at the same time expressing concern about behavioral health, alternative payment systems, and reaching underserved populations. He noted that minorities have difficulty navigating the health care system, and that it is imperative to “make sure the health care system is accessible and effective for all.”

Morning presentations included those from David Seltz, executive director of the Health Policy Commission; Aron Boros, executive director of CHIA, and Michael E. Chernew, Ph.D., Professor in the Department of Health Care Policy at Harvard Medical School. Other expert speakers scheduled include Alan Weil, J.D., Editor-in-Chief, Health Affairs, and Thomas Lee, M.D., Chief Medical Officer of Press Ganey Associates.

The hearing concluded at the end of the day on Tuesday. Written testimony, agency reports, and expert presentations are available on the HPC’s website at www.mass.gov/hpc. Live streaming of the hearing is also available from the website.

News coverage of hearings:

Health care stakeholders size up cost-control bid
State House News Service via Worcester Business Journal, October 7, 2014

 

 

Recapping a Busy Year: MMS Health Care Advocacy in 2014

Posted in Annual Meeting 2014, Electronic health records, Health Reform, meaningful use, Medical Marijuana, Medicare, Payment Reform on May 15th, 2014 by MMS – Comments Off on Recapping a Busy Year: MMS Health Care Advocacy in 2014

Ronald W. Dunlap, MD, president of the Massachusetts Medical Society, kicked off the Society’s 2014 Annual Meeting with a review of five significant advocacy issues from the 2013-14 year:

  • Medicare payment
  • ICD-10 deadlines
  • Regulatory overreach
  • State regulations on EHRs
  • Medical Marijuana

 

MMS 2014 Public Health Leadership Forum: The Impact of Health Care Reform on Health Care Disparities

Posted in Health Reform, Payment Reform on April 7th, 2014 by Erica Noonan – 1 Comment

The key to lessening health care disparities lies in better data collection, pay-for-performance systems that properly measure and reward improvement, and technology that engages patients in their own treatments, according to according to a panel of experts featured at the 2014 MMS Public Health Leadership Forum.

The presentation, “The Impact of Health Care Reform on Health Care Disparities,” was hosted by MMS April 4 in collaboration with the national Commission to End Health Care Disparities.

As one of the first states to pioneer universal health coverage, the nation is looking to Massachusetts for ideas and solutions as this year’s implementation of the Affordable Care Act is expected to bring millions of previously uninsured patients into doctors’ offices, said MMS President Ronald Dunlap.

Massachusetts has lower-than-average rates of disparities in key health areas such as infant mortality, hypertension, obesity and adult diabetes.  But access to primary care physicians in certain regions of the state remains a problem, as do Medicaid payment models that dis-incentivize physicians, said Dr. Dunlap.

Dr. Joel Weissman

Joel Weissman, PhD

Can Pay-for-Performance Create Equity?

Among the most promising tools for bridging the gaps are new payment models that measure and reward reductions in disparities, said Joel Weissman, PhD, Deputy Director and Chief Scientific Officer Center for Surgery and Public Health at Brigham and Women’s Hospital.  “No information means no improvement,” he said.

But most current pay-for-performance models are not effectively addressing disparities and creating incentives that could reduce them.  “Not only do we need to know more about measures that are “disparities-sensitive”, but how to select measures that are ready to have an impact on clinical practice, and how to represent differences in a statistically meaningful and policy-relevant way,” Weissman said.

Dr. John Moore

John Moore, MD

Patient Empowerment Through Technology

Grassroots approaches to health, including personalized patient engagement and “navigators,” who help patents cut through red tape to get social services are already helping reduce disparities in some areas.

John Moore, M.D., CEO and co-founder of Twine Health, said the new health models must also include the patient as “an active participant.”  The old-fashioned paternalistic doctor-patient relationship is fading away, he said. Patients of the future will set their own health care goals and meet them using technology and peer support.

The approach has already worked, he said, citing his study published in 2013 in the Journal of Clinical Outcomes Management that found hypertension controlled in a group of patients for less than 30 percent of the average annual Medicare cost for the same outcome.

Sonia Sarkar

Sonia Sarkar, MPH

Making Physician Advice Actionable in the Moment

Another effective disparities-reducing program has been Boston-based Health Leads, which connects patients to advisors who will coordinate the nitty-gritty details of social services and enter the information on a patient’s EMR for physicians to track and follow-up, said Sonia Sarkar, the company’s chief of staff to the CEO.

The program has partnered with major medical centers in Boston, Providence, Baltimore, Chicago, New York and Washington D.C. and helps them close disparity gaps for patients without resources to get or remain healthy. Connecting patients at risk of disparities to needed food, heat, child care, transportation or other services makes “the doctor’s advice actionable in the moment,” Sarkar said.  “It insures health care delivery is centered around health.”

See the full forum agenda and download the presentations here.

–Erica Noonan

The President’s Podium: Physician, Inc.

Posted in Health Policy, Health Reform, Leadership, Payment Reform, Regulation on March 18th, 2014 by MMS Communications – Comments Off on The President’s Podium: Physician, Inc.

By Ronald Dunlap, M.D., President, Massachusetts Medical Society

In my first post on this site last August, I called attention to a survey of DSC_0003 Dunlap 4x6 color 300 ppi_editednearly 3,500 physicians that found that 60 percent of physicians would not recommend their profession as a career.

I suggested that the finding was not surprising, as the high level of discontent within our profession is due mostly to the growing business and administrative requirements of medicine that we must meet and maintain. As we began our medical careers, few of us thought we would become “providers” in the health care “industry.”

The March edition of our member newsletter, Vital Signs, recognizes this reality with the theme of The Business of Being a Physician.  My President’s Message in that issue said “we cannot pretend that we can divorce ourselves from the financial realities battering the health care industry.”  Like it or not, the establishment of business principles in the profession of medicine long ago stopped being a trend; it has been a reality to an increasing extent, and is now widespread.

The business and financial aspects of medicine weigh on all of us. They threaten the viability of many practices and push physicians to make hard choices about their profession and careers.  They intrude into the physician-patient relationship, steal time from engaging our patients, and erode the control we should have over how we practice medicine and how we care for our patients.

The legislative, regulatory, and commercial mandates and requirements continue to increase. Some of these changes are positive; some not so much so. Collectively, however, they present enormous challenges.

At the Federal level, the Affordable Care Act has set regulations on such areas as quality reporting, physician ownership and referrals, medical homes, accountable care organizations and payment practices.  The presence of the Independent Payment Advisory Board, despite its inactivity, still looms, and the explosion of billing codes, known as the ICD-10, is scheduled to take effect later this year.

At the state level, legislative efforts such as Chapter 224 have added more requirements: insurance regulations governing such newly-named entities as “Risk-Bearing Provider Organizations,” proficiency with electronic medical records, and price transparency, just to name a few.  Regulations and requirements from insurers and regulators further add to our administrative load.

We are being inundated with compliance measures and calls for metrics and analytics and other databases, even when many practices are ill-equipped to provide such information given inadequate or nonexistent health information technology systems.

The Medical Society continues to speak out on these issues. In testimony before the Massachusetts Health Policy Commission in February, I pointed out that the rising number of requirements asked of physicians takes time away from patient care, adds to administrative demands, and raises the costs of practicing medicine.  I further said such requirements will drive small to mid-sized practices to merge or align with larger entities that have the ability to meet such requirements and that this could lead to further consolidations and higher costs in the health care market –a phenomenon already well underway in the Commonwealth.

On the national level, rising physician frustration with the direction of medicine is leading more of our colleagues into the political arena. A New York Times report of March 8  noted that “a heightened political awareness and a healthy self-regard that they could do a better job, are drawing a surprising large number [of physicians] to the power of elective office.”

Such political activism by physicians is rare at the state level.  Whether more physicians in national office, while a hopeful sign, will affect change remains to be seen. But it is likely to alter one critical dynamic: bringing added weight to the voice of physicians in the conversation about health care.  That is a key development.

It is imperative that those who propose changes to the practice of medicine recognize and understand how the consequences of those changes – intended and unintended – will affect the practice of medicine.  Who better to tell them than those of us on the front lines of patient care?  We must accept that we’re now part of an “industry” and that the “business of medicine” is here to stay due to cost constraints. It is necessary however, for physicians to have an unmistakable and conspicuous voice in how that business operates.

The President’s Podium appears periodically on the MMS Blog, offering Dr. Dunlap’s commentary on a range of issues in health and medicine.   

Medical Price Transparency Law Rolls Out: Physicians Must Help Patients Estimate Costs

Posted in Health Reform, Payment Reform on January 3rd, 2014 by Erica Noonan – 15 Comments

Massachusetts physicians and hospitals are now required by law to provide cost information for procedures and services to patients who request it.

The new price transparency regulations became effective for physicians and hospitals on January 1, 2014.

Health insurers have been required to provide information on cost estimates for office visits to physicians and specific tests and procedures since October 2013.

Additionally, the provider must give patients any information—such as CPT codes—that their insurer needs to calculate what their out-of-pocket costs will be.

The new requirement is part of an ongoing rollout of Chapter 224, sweeping payment reform legislation passed in August 2012 that seeks to improve health care quality while reducing costs through various strategies, including alternative payment methodologies and increased price transparency.

What Physicians Need to Do •	Provide the patient with the CPT codes for all anticipated services and procedures. Patients will provide those codes to their health plan to obtain the contracted costs for the professional services, facility fees, and out of pocket costs related to the request. Patients should also be given the phone number of the facility’s billing office, which may be able to provide additional information about facility costs. •	Cooperate with health plans’ requests for further information in a timely fashion, to help the health plans make the most accurate estimates possible for your patients.

State officials have said they hope the new rules will transform the health care industry by allowing patients to easily obtain medical cost information and comparison shop for their care.

The law states that if asked by a patient, a health care provider must disclose the allowed amount or charge of the admission, procedure or service, including the amount for any “facility fees” required within two working days. The law defines “allowed amount” as the contractually agreed amount paid by a carrier to a health care provider.

The law also compels providers who participate in networks to provide “sufficient” information about the proposed procedure or service to allow a patient to use the network’s toll-free telephone number and website established to disclose costs.

According to guidelines to carriers issued in mid-December by the Division of Insurance, insurers are expected to communicate with providers, after securing patient permission, to obtain enough information to determine price information and cost data.

“It is anticipated that providers will cooperate with carrier requests to provide such information to consumers and carriers should endeavor to give providers a reasonable time within which to provide the information,” the memo said.

The Massachusetts Office of Consumer Affairs and Business Regulations has compiled a directory of websites and phone numbers at the health plans to help consumers  get the precise estimates of the total of a specific service or procedure, including out of pocket costs.

The MMS has developed a sample information form that physicians and practice staff can fill and give to patients, which can then be given to insurers.

Although the new law has dramatic implications, many consumers seem so far unaware of their new rights to cost information.

Blue Cross Blue Shield of Massachusetts has been averaging less than three a day, according to Bill Gerlach, director of member decision support. Physicians may experience a similar trickle of requests, but as the law becomes better known among patients and more of them move to high deductible plans, that may change, say some observers.

Many physicians are also just learning about the new requirement and wonder how it will work on a day-to-day practice level.

Partners In Internal Medicine’s George Abraham, M.D., worries that patients will get so frustrated by the multiple phone calls they’ll have to make to gather the various cost components that they’ll just give up.

“On paper it looks great. We’ve increased transparency, but in reality it’s mired in red tape,” said Dr. Abraham. “It could take days for patients to get all the information they need. It’s not user-friendly.”

Atrius Health said it hopes its providers—and patients—will have a fairly easy time getting health care cost information. It has implemented a software program that gives providers easy access to not only their own charges, but also information from the insurance company about patients’ out-of-pocket costs.

“It provides a one-page report for patients that tells them how much we typically get reimbursed by the plan and what the deductible and co-pay would be—and where they are in their deductible—based on the insurance product,“ said Chief Medical Officer Richard Lopez, M.D.

There are a few caveats, to the Atrius system, however. It is populated with insurance data from only the state’s largest insurers and, as with other practices, lacks cost information for providers outside the Atrius organization. He conceded that most physician practices do not have the resources to implement something similar.

Bruce Leslie, M.D., of Newton Wellesley Orthopedic Associates, said he supports the intent of the new price transparency law, and even sees a potential upside for community practices like his.

“We suspect our costs are less than [those] at the big academic centers so this could be a good marketing opportunity for us,” said Dr. Leslie.

Vicki Ritterband, Vital Signs Staff Writer

Interim Meeting Ethics Forum: Ethics in ACOs

Posted in Accountable Care Organizations, Ethics Forum, Global Payments, Health Policy, Health Reform, Interim Meeting 2013, Payment Reform on December 6th, 2013 by MMS Communications – 2 Comments
Susan Dorr Goold, MD

Susan Dorr Goold, MD

The accountable care organization (ACO), loosely defined as a group of providers that accepts responsibility for the total care of a patient and is accountable for high quality care and the cost of care, is a rapidly growing concept whose aim is to reduce the rising costs of care and improve quality.

While the emphasis on ACOs has focused on cost and outcomes, less attention has been paid to the ethical considerations of delivering care within such a structure.  As the ACO continues to evolve, what are the ethical issues that physicians might face as they practice medicine?  Do healthcare institutions, as well as individual providers, face ethical issues as organizations? And how might ethical considerations influence payment structures?

These are some of the issues discussed at the Ethics Forum, held on the first day of the 2013 MMS Interim Meeting of the House of Delegates.

Presenting were Susan Dorr Goold, MD, professor at the University of Michigan and Chair of the American Medical Association’s Council on Ethical and Judicial Affairs, and Philip F. Gaziano, MD, chairman and CEO of Accountable Care Associates, a Springfield-Mass. based healthcare management company.

In two presentations over two hours, delegates heard perspectives on the practical and ethical challenges in making a transition to an ACO, who providers are accountable to and for what within an ACO while maintaining their first loyalty to the patient, conflicts of interest that may arise, and ways to protect patient autonomy while practicing in an ACO.

Some highlights from the presenters:

Dr. Goold, in a presentation entitled Strengthening Patient-Physician Trust in Accountable Care Organization, examined the elements of personal and organizational accountability that lead to strong physician-patient relationships.  Professionals, organizations and patients all have a responsibility in strengthening trust, she said: professionals with a duty to “seek trust from patients” based on openness and honesty, patients by being truthful and to trust wisely, and organizations as “moral characters” in modern society.

Dr. Gould also outlined the challenges to trust in physicians (patient expectations, requests, and demands) and health care institutions such as hospitals and payers (safety of personal information, treatment decisions, fair and prudent use of resources). She concluded with the notion that physicians and healthcare institutions have “moral responsibilities in health care” to include advocacy, competence, fairness, and honesty, among others.

Dr. Gaziano’s Ethical Considerations in Accountable Care Organizations focused on the payment considerations with ACOs, comparing fee-for-service to global payments (payments based on Relative Value Units) to Quality Value Units, a new designation created by his firm that provides the advantages of tracking and reporting in real time, predictive value, and the tracking of quality and budgets. He also addressed physician concerns: why ACOs are different from earlier cost-saving attempts like HMOs and opportunities within the new system of ACOs such as payments and managing budgets.

The presentations of both physicians are available on the MMS website here.

 

2013 MMS Interim Meeting Opens With Call to Protect Smaller Practices

Posted in Health Reform, Interim Meeting 2013, Payment Reform on December 6th, 2013 by Erica Noonan – 1 Comment

Massachusetts Medical Society President Ronald Dunlap, M.D. opened the 2013 Interim Meeting with a call for the organization to support small and mid-sized physician practices during an unprecedented push towards clinical and financial alignment statewide.

“I believe that if a physician or a practice wants to maintain a meaningful degree of professional autonomy, they should be able to do so. Becoming employed by a large system is not for everyone,”  said Dr. Dunlap in his President’s Report to the MMS House of Delegates. “In fact, it is not even necessary.”

Oversight may be needed to ensure that hospitals continue to maintain relationships with affiliated, as well as  employed physicians, and do not attempt to use their market power to dictate terms to independent physician groups, Dr. Dunlap said.

The MMS  plans to continue its outreach on clinical integration challenges facing physicians this into the coming year, Dr. Dunlap said.  The Society’s Physicans Guide to ACOs, created earlier this year, has become one of the most popular documents ever posted on the MMS website.

“We will work hard on the advocacy front to ensure that the rules of the game give everyone the opportunity to be successful — to ensure that we’re not all stuffed into a single model that cannot possible work for everyone,” said Dr. Dunlap.

More than 150 physician HOD representatives traveled from around the state to Waltham on Dec. 6 for the two-day Interim Meeting. They will vote on a number of  formal resolutions, and craft MMS policy for the coming year.

The Delegates also welcomed Aron Boros, Executive Director of the Center for Health Information and Analysis, a state agency created to collect and distribute meaningful health care cost data under Chapter 224, the payment  reform law of 2012.

“The chief health care complaint in Massachusetts truly is affordability,” Boros said.  The cost of health care in Massachusetts is  well above the national average because of  a complex delivery system that withholds information about price and cost from patients and physicians, he said.

The lack of accurate and meaningful data on outcomes and provider quality means the health care system is too often treated like an “all-you-can-eat buffet.”

Beginning in 2015, Boros said, CHIA and the state’s Health Policy Commission will become directly involved with health plans and providers whose health care costs grow faster than the state’s economic growth rate of 3.6 percent annually.

– Erica Noonan

 

 

MMS Forum Spotlights the Past, Present and Future of Health Reform

Posted in Accountable Care Organizations, Affordable Care Act, Health Reform, Payment Reform on October 30th, 2013 by MMS – 1 Comment
David Gergen

David Gergen

On the same day that President Obama spoke at Faneuil Hall to defend and promote the Affordable Care Act, the Massachusetts Medical Society’s 14th annual forum on the State of the State’s Health Care focused on the consequences and future of state and federal health reform.

Calling the ACA “both a triumph and a tragedy,” veteran White House advisor David Gergen said the political firestorm currently surrounding ACA implementation – reports of consumers furious that their private insurance policies face cancellation – has seriously jeopardized the future of President Obama’s signature legislation.

Gergen, currently director of the Center for Public Leadership at Harvard’s Kennedy School of Government, recommended a major public information campaign and more transparency from President Obama to rally public support for the beleaguered law.

Stuart Altman

Stuart Altman

Stuart Altman,  chair of the Massachusetts Health Policy Commission, spoke about the need for states to become more aggressive about reining in total health care spending – not  just  the amount public money spent to care for low-income or elderly patients.

Because health care costs are disproportionately pushed onto the privately insured, the long-running cost-shifting model is unsustainable.  “It is simply impossible for private insurance to make up for shortfalls in Medicare and Medicaid rates,” said Altman, a Brandeis professor who currently chairs the state’s Health Policy Commission.

He predicted a noticeable decline in medical care nationwide if costs are not more quickly brought under control and tightly connected to quality and outcome data. “Not a `lights-out,’ but more like a `lights flickering,’” he said.

Altman, a supporter of physician-led ACOs and bundled payment systems in Massachusetts, said the state’s new innovated approaches strive to avoid the “mistakes” of 1990s-era managed care systems, such as micromanaging doctors, dumping too much financial risk on providers, and forcing unwilling consumers to join plans.

Control of post-acute care spending and an effective primary care system will be keys to the future success of Massachusetts ACOs, Altman said.

John Noseworthy, MD

John Noseworthy, MD

Mayo Clinic CEO John Noseworthy, MD, spoke about his system’s culture of teamwork and patient-centered care.  He said more work is needed in most other health care systems nationwide to reduce fragmented and uneven care – factors that drive up the costs of care dramatically.

The Mayo system struggles with downward pressure on Medicare reimbursement rates, and Dr. Noseworthy said he expected the ACA would likely cut them an additional 15 to 25 percent.

While Mayo has six campuses nationwide, Dr. Noseworthy said his system’s survival lies not in acquisitions or consolidation, but in scaling its practice knowledge and experience to affiliates at independent practices and hospitals.  “We hope that our network can be an integrator for groups without the culture of an integrated practice,” he said.

The program also featured a panel of Massachusetts health care executives: Tufts Health Plan CEO James Roosevelt Jr., Boston Medical Center CEO Kate Walsh, and Stuart A. Rosenberg, MD, CEO of the Harvard Medical Faculty Physicians at BIDMC.

Dr. Rosenberg said he felt one of the most pressing problems was a failure to use IT to transform health care and help patients manage chronic health issues in their own homes.

Roosevelt urged more collaboration between providers and payers to control costs, and said the state must be vigilant in monitoring provider consolidation to ensure better care for patients is the result.

In her comments, Walsh focused on BMC’s dramatic financial turnaround in the wake of major state funding cuts.

But, Walsh warned, the state must stay vigilant in monitoring the needs of its poorest citizens “or access will be slaughtered on the altar of costs.”

—     Erica Noonan